What is the most appropriate oral antithrombotic therapy for a 73-year-old female with a history of hypertension, hyperlipidemia, type 2 diabetes mellitus, and smoking, presenting with symptoms of a stroke, including right facial droop, right-sided weakness and numbness, and global aphasia, with 80% stenosis in the left middle cerebral artery?

From the Guidelines

The most appropriate oral antithrombotic therapy for AL at this time is aspirin 81 mg daily plus clopidogrel 75 mg daily for 21 days, followed by aspirin 81 mg daily indefinitely. This recommendation is based on guidelines for the prevention of stroke in patients with ischemic stroke or transient ischemic attack, which suggest that antiplatelet agents rather than oral anticoagulation are recommended to reduce the risk of recurrent stroke and other cardiovascular events 1. The use of aspirin and clopidogrel as initial therapy is supported by the guidelines, which state that both are acceptable options for initial therapy (Class IIa, Level of Evidence A) 1. Key points to consider in this decision include:

• The patient's noncardioembolic ischemic stroke, indicated by the absence of acute hemorrhage on CT scan and significant stenosis in the left middle cerebral artery.
• The patient's high risk of recurrent stroke due to multiple vascular risk factors, including hypertension, hyperlipidemia, type 2 diabetes, and significant smoking history.
• The guidelines' recommendation against the routine use of dual antiplatelet therapy beyond the initial period due to increased risk of hemorrhage (Class III, Level of Evidence A) 1.
• The importance of individualizing the selection of an antiplatelet agent based on patient risk factor profiles, tolerance, and other clinical characteristics 1. Given these considerations, the chosen regimen provides a balanced approach to reducing the risk of recurrent stroke while minimizing the risk of bleeding complications.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Antithrombotic Therapy Options

The patient, AL, has a history of hypertension, hyperlipidemia, type 2 diabetes mellitus, and smoking, and has presented with sudden-onset right facial droop, right-sided weakness and numbness, and global aphasia. Given her condition, the most appropriate oral antithrombotic therapy needs to be determined. The options are:

• Aspirin 81 mg daily plus clopidogrel 75 mg daily for 21 days, followed by aspirin 81 mg daily indefinitely
• Aspirin 81 mg daily plus prasugrel 10 mg daily for 90 days, followed by aspirin 81 mg daily indefinitely
• Aspirin plus dipyridamole (25 mg/200 mg) 1 capsule twice daily indefinitely
• Aspirin 325 mg daily indefinitely

Considerations for Antithrombotic Therapy

Considering AL's condition and the provided evidence, the following points are relevant:

• The patient has 80% stenosis in the left middle cerebral artery, which is a significant factor in determining the appropriate antithrombotic therapy 2.
• The use of dual antiplatelet therapy (DAPT) has been studied in various contexts, including after left atrial appendage occlusion, and has been shown to have a higher risk of bleeding compared to low-dose direct oral anticoagulation (DOAC) 3.
• Direct angioplasty has been explored as a treatment option for acute ischemic stroke due to intracranial atherosclerotic stenosis-related large vessel occlusion, with promising results 4.
• The patient's National Institutes of Health Stroke Scale score is 3, indicating a mild stroke, and the presence of large vessel occlusion may lead to worse outcomes if not treated promptly 5.

Most Appropriate Antithrombotic Therapy

Based on the provided evidence, the most appropriate oral antithrombotic therapy for AL at this time is:

• Aspirin 81 mg daily plus clopidogrel 75 mg daily for 21 days, followed by aspirin 81 mg daily indefinitely, as this regimen is commonly used in patients with acute ischemic stroke and has been shown to be effective in reducing the risk of recurrent stroke 6, 2.